Provider Demographics
NPI:1295874451
Name:REZNICK, TERRY M (DO)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:M
Last Name:REZNICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2429 MARGARET DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-8842
Mailing Address - Country:US
Mailing Address - Phone:810-629-5776
Mailing Address - Fax:
Practice Address - Street 1:5065 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1037
Practice Address - Country:US
Practice Address - Phone:810-230-0338
Practice Address - Fax:810-230-0595
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0152511075OtherBLUE CROSS BLUE SHIELD
MI4752012Medicaid
MI4752012Medicaid
MI0152511075OtherBLUE CROSS BLUE SHIELD